DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5-300 (5W) San Francisco, CA 94103-6706

DIVISION OF MEDICAID & CHILDREN’S HEALTH OPERATIONS

December 12, 2016

Mari Cantwell Chief Deputy Director, Health Care Programs California Department of Health Care Services P.O. Box 997413, MS 0000 Sacramento, CA 95899-7413

Dear Ms. Cantwell:

Enclosed is an approved copy of California State Plan Amendment (SPA) 16-008, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 29, 2016. This amendment places the Comprehensive Perinatal Service Program (CPSP) providers under the clinic benefit as part of the reimbursement for Indian Health Service (IHS) and Tribal 638 facilities and makes related clarifications.

The effective date of this SPA is January 1, 2016. Enclosed are the following approved SPA pages that should be incorporated into your approved state plan:

• Attachment 4.19-B, page 6c• Supplement 6 Attachment 4.19-B, pages 1, 2 and 2a

If you have any questions, please contact Cheryl Young at 415-744-3598 or via email at Cheryl.Young@cms.hhs.gov.

Sincerely,

/s/

Henrietta Sam-Louie Associate Regional Administrator Division of Medicaid & Children’s Health Operations

cc: Cynthia Owens, California Department of Health Care Services (DHCS) Jim Elliott, DHCS Erica Greilich, DHCS Katherine Neto, DHCS Nathaniel Emery, DHCS Wendy Ly, DHCS

42 CFR 447 Subpart F; SSA section 1905(b);

Supplement 6 to Attachment 4.19-B, page 1 Supplement 6 to Attachment 4.19-B, page 1 Supplement 6 to Attachment 4.19-B, page 2aSupplement 6 to Attachment 4.19-B, page 2aAttachment 4.19-B, page 6c Attachment 4.19-B, page 6c

ORIGINAL SIGNED

March 29, 2016 December 12, 2016

January 1, 2016 /s/Associate Regional Administrator

Henrietta Sam-Louie Division of Medicaid & Children's Health Operations

Box 6: Pen & ink change to add citations per RAI response dated 8/10/16.

Box 8 & 9: Pen & ink change to add pages per CA email dated 11/1/16.

Attachment 4.19-B Page 6C

midwife, clinical psychologist, licensed clinical social worker, or visiting nurse, hereafter referred to as a "health professional," to the extent the services are reimbursable as covered benefits under C.l.(a). For purposes of this subparagraph 2(a), "physician" includes the following:

(i) A doctor of medicine or osteopathy licensed by the State to practice

medicine and/or surgery and who is acting within the scope of his/her license.

(ii) A doctor of podiatry licensed by 'the State to "practice podiatric medicine

and who is acting within the scope of his/her license.

(iii) A doctor of optometry licensed by the State to practice optometry and who is acting within the scope of his/her license.

(iv) A chiropractor licensed by the State in the practice of chiropractic and

who is acting within the scope of his/her license.

(v) A doctor of dental surgery (dentist) licensed by the State to practice dentistry and who is acting within the scope of his/her license.

Inclusion of a professional category within the term "physician" is for the purpose of defining the professionals whose services are reimbursable on a per visit basis, and not for the purpose of defining the types of services that these professionals may render during a visit (subject to the appropriate license).

(b) Comprehensive perinatal services when provided by licensed and/or certified

practitioners who are able to render covered services in accordance with their scope of practice as identified in California statute.

TN No. 16-008 Supersedes Approval Date: December 12, 2016 Effective Date: July 1, 2016 TN No. 11-037a

State Plan for Title XIX Supplement 6 Attachment 4.19-B California Page 1

REIMBURSEMENT FOR INDIAN HEALTH

SERVICES AND TRIBAL 638 HEALTH FACILITIES California will reimburse federally recognized tribal "638" facilities in accordance with the most recent rate published in the Federal Register.

1. IHS/Tribal 638 facilities are reimbursed at the all-inclusive rate

for each encounter.

2. An IHS clinic encounter is defined as a face-to-face encounter provided in the tribal facility between a tribal patient and the health professional (as specified on page 2) of the clinic or the center.

3. The IHS MOA clinics may bill for up to two visits a day for one patient, if

one is a medical visit and the other is another health visit.

4. Encounters with the health professionals listed on page 2 may be billed under the IHS all-inclusive rate.

TN No. 16-008 Supersedes Approval Date: Dec. 12, 2016 Effective Date: 1/1/16 TN No. 09-001

State Plan for Title XIX Supplement 6 Attachment 4.19-B California Page 2

REIMBURSEMENT FOR INDIAN HEALTH SERVICES AND TRIBAL 638 HEALTH FACILITIES

A. Below is a list of health professionals that may bill under the IHS all-inclusive rate:

• Physician • Physician Assistant • Nurse Practitioner • Nurse Midwife • Registered Dental Hygienists • Registered Dental Hygienists in Extended Functions • Registered Dental Hygienists in Alternative Practice • Clinical Psychologist • Clinical Social Worker • Marriage and Family Therapist • Visiting Nurse if services are provided in the Tribal facilities • Under the Early and Periodic Screening, Diagnostic, and Treatment Program (EPSDT), the

services of Licensed Marriage, Family and Child Counselors are available as 'other health visit' to persons under 21 years of age, as a result of an EPSDT screening which identifies the need for a service which is necessary to correct or ameliorate a mental illness or condition.

B. Comprehensive Perinatal Services Program (CPSP) providers who are licensed and/or certified practitioners who are able to render covered services in accordance with their scope of practice as identified in California statute. A September 17, 1985 HCFA letter allows these services as a physician or clinic service.

C. In addition, below is a list of interns that may provide Medi-Cal psychology services.

• Registered Marriage and Family Therapists Interns • Registered Associate Clinical Social Workers • Psychological Assistants

Interns must be under the supervision of a licensed mental health professional, in accordance with the requirements of applicable state laws.

D. Except for the services specified under Item E below, the following other ambulatory services, but not limited to, provided by health professional can be billed under the IHS all-inclusive rate. • Medical and surgical services provided by a doctor of dental medicine or dental surgery, which if

provided by a physician would be considered physician services • Physical Therapy • Occupational Therapy • Drug and Alcohol visits (Subject to Medi-Cal provider participation requirements) • Telemedicine and teledentistry (No additional live transmission costs will be reimbursed) • Optometry (Eyeglasses and other eye appliances are restricted to beneficiaries identified under

Item E below)

TN No. 16-008 Supersedes Approval Date: Dec. 12, 2016 Effective Date: July 1, 2016 TN No. 15-010

State Plan for Title XIX Supplement 6 Attachment 4.19-B California Page 2a

E. Acupuncture, audiology, chiropractic, eyeglasses and other appliances, podiatry, and speech therapy are covered benefits under this state plan only for the following beneficiaries:

1. Pregnant women, if the optional benefit is part of their pregnancy-related services or services for a condition that might complicate the pregnancy.

2. Individuals who are eligible for the Early and Periodic Screening, Diagnostic and Treatment benefit.

TN No. 16-008 Supersedes Approval Date: Dec. 12, 2016 Effective Date: July 1, 2016 TN No. 14-012